Inspection Reports for Grand Islander Center
333 GREEN END AVENUE, RI, 02842
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 1, 2025
Visit Reason
An off-site desk audit was conducted to review all previous deficiencies cited on May 14, 2025, and to verify the facility's compliance based on the submitted plan of correction and supporting documentation.
Findings
All previously cited deficiencies have been corrected, and the facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Jun 30, 2025
Visit Reason
A revisit survey was conducted on June 30, 2025 for all previous deficiencies cited on May 15, 2025, Life Safety Code survey.
Findings
All deficiencies have been corrected at this time. The facility is in compliance with all regulations surveyed.
Inspection Report
Annual Inspection
Census: 115
Capacity: 146
Deficiencies: 9
May 14, 2025
Visit Reason
A recertification and complaint survey was conducted from 5/12/2025 through 5/14/2025 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were identified related to comprehensive care plans, skin integrity, activities, nutrition/hydration, nursing services, medication administration, infection control, and life safety code compliance. Plans of correction were submitted for each deficiency with timelines for staff re-education and audits.
Complaint Details
The survey included complaint reference numbers 100653, 100666, 100689, and 100791. Findings were substantiated as deficiencies related to care plans, skin assessments, activities, nutrition, nursing services, medication administration, infection control, and life safety.
Deficiencies (9)
| Description |
|---|
| Failure to develop and implement comprehensive person-centered care plans with measurable objectives and timelines for weekly skin assessments for residents #29, 32, and 172. |
| Failure to provide an ongoing program to support residents' choice of activities, including TV availability for residents #2, 86, and 99. |
| Failure to prevent pressure ulcers and provide necessary treatment for residents, including resident #43 with pressure ulcers. |
| Failure to maintain acceptable nutritional parameters and implement nutritional interventions for resident #173 with significant weight loss. |
| Failure to provide appropriate care and monitoring for residents with PICC lines, including resident #173. |
| Failure to ensure sufficient nursing staff competencies and skills to provide nursing and related services, including medication administration via PICC line. |
| Failure to maintain infection prevention and control program, including enhanced barrier precautions and antibiotic stewardship. |
| Failure to maintain fire safety code compliance, including means of egress and fire drills. |
| Failure to properly manage resident personal needs funds in accordance with state regulations. |
Report Facts
Capacity: 146
Census: 115
Deficiencies cited: 9
Audit frequency: 1
Re-education completion date: Jun 30, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Keady | Executive Director | Signed the initial comments and plan of correction on June 9, 2025 |
| Director of Nursing | Director of Nursing | Responsible for re-education and audits related to skin care, pressure ulcers, PICC line care, and nursing competencies |
| Activity Director | Activity Director | Responsible for audits related to resident activities and TV availability |
| Director of Maintenance | Maintenance Director | Responsible for fire safety and means of egress compliance |
| Business Office Manager | Business Office Manager | Responsible for re-education and auditing of personal needs funds management |
Inspection Report
Complaint Investigation
Census: 123
Capacity: 142
Deficiencies: 10
May 31, 2024
Visit Reason
A Recertification Survey and complaint investigation was conducted at Grand Islander Center from 5/28/2024 through 5/31/2024 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including a State licensure and emergency preparedness survey.
Findings
Deficiencies were cited related to professional standards of care, hearing and vision treatment, mobility, bowel/bladder incontinence, dialysis, dental services, food safety, infection prevention and control, and life safety code violations. Corrective actions and systemic changes were implemented with ongoing monitoring plans.
Complaint Details
The survey included a complaint investigation referenced by ACTS Reference Number 96937. The complaint related to deficiencies in care and services provided to residents, including diet, hearing aids, mobility, bowel/bladder care, dialysis, dental services, food safety, infection control, and life safety compliance.
Deficiencies (10)
| Description |
|---|
| Services Provided Meet Professional Standards CFR(s): 483.21(b)(3) |
| Treatment/Devices to Maintain Hearing/Vision CFR(s): 483.25(a)(1)(2) |
| Increase/Prevent Decrease in ROM/Mobility CFR(s): 483.25(c)(1)-(3) |
| Bowel/Bladder Incontinence, UTI CFR(s): 483.259(e)(1)-(3) |
| Dialysis CFR(s): 483.25(f) |
| Routine/Emergency Dental Services in NFs CFR(s): 483.55(b)(1)-(5) |
| Food Procurement, Store, Prepare, Serve - Sanitary CFR(s): 483.60(i)(1)(2) |
| Provide/Obtain Specialized Rehab Services CFR(s): 483.65(a)(1)(2) |
| Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f) |
| Life Safety Code - Sprinkler System - Installation CFR(s): NFPA 101 |
Report Facts
Capacity: 142
Census: 123
Deficiencies cited: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maureen Welch | Administrator | Signed plan of correction on 6/1/2024 |
Inspection Report
Annual Inspection
Deficiencies: 6
Apr 27, 2023
Visit Reason
A Recertification Survey was conducted at Grand Islander Nursing Home from 04/25/2023 through 04/27/2023 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities. A State licensure and emergency preparedness surveys were also conducted at this facility.
Findings
Deficiencies were cited as a result of this survey including failure to develop and implement comprehensive care plans, failure to meet professional standards related to blood sugar monitoring, failure to maintain a safe environment free of accident hazards, failure to ensure drug regimens were free from unnecessary drugs, and failure to comply with food safety requirements. The emergency preparedness plan was also found deficient for failure to conduct required exercises and review the plan annually. No Life Safety Code deficiencies were identified.
Deficiencies (6)
| Description |
|---|
| Failure to implement a comprehensive person-centered care plan for 1 of 2 residents reviewed related to wandering. |
| Failure to ensure services met professional standards of quality related to blood sugar monitoring for 1 of 4 residents reviewed. |
| Failure to ensure resident environment remained free of accident hazards for 2 of 4 housekeeping closets observed unlocked containing hazardous chemicals. |
| Failure to ensure drug regimen was free from unnecessary drugs for 2 of 3 residents reviewed. |
| Failure to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. |
| Failure to develop and maintain an emergency preparedness plan that was reviewed and updated at least annually and failure to conduct required exercises to test the plan. |
Report Facts
Residents reviewed for care plan deficiency: 2
Residents reviewed for blood sugar monitoring: 4
Housekeeping closets observed unlocked: 2
Residents reviewed for unnecessary drugs: 3
Residents affected by emergency preparedness deficiency: 103
Inspection Report
Complaint Investigation
Deficiencies: 11
May 19, 2022
Visit Reason
A Recertification and Complaints Investigation Survey was conducted from 05/16/2022 through 05/19/2022 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including a complaint investigation triggered by a community reported complaint received by the Rhode Island Department of Health on 05/18/2022.
Findings
The facility failed to transcribe a Lithium order correctly, resulting in a resident receiving 10 additional doses and subsequent hospitalization for lithium toxicity. Deficiencies were identified at the Immediate Jeopardy level and multiple regulatory requirements related to nutrition/hydration status, physician visits, competent nursing staff, nurse aide training, drug regimen review, and abuse/neglect training were cited.
Complaint Details
Complaint investigation was initiated based on a community reported complaint received by the Rhode Island Department of Health on 05/18/2022 alleging a resident was administered Lithium 300 mg every day instead of every other day as ordered, resulting in harm.
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to transcribe a Lithium order correctly, resulting in resident receiving 10 additional doses and hospitalization for lithium toxicity. | Immediate Jeopardy |
| Failed to maintain acceptable nutrition and hydration status for residents, including failure to ensure re-weighing and notification of significant weight changes. | — |
| Failed to ensure physician review of resident's total program of care including medications and treatments at each visit. | — |
| Failed to ensure sufficient nursing staff with appropriate competencies and skills to care for residents. | — |
| Failed to complete performance review and provide regular in-service education for nurse aides. | — |
| Failed to provide sufficient staff training on behavior health needs and trauma informed care. | — |
| Failed to ensure monthly drug regimen review and act on identified irregularities. | — |
| Failed to ensure resident drug regimen is free from unnecessary drugs. | — |
| Failed to ensure residents are free of significant medication errors. | — |
| Failed to provide required in-service training for nurse aides including dementia management and abuse prevention. | — |
| Failed to provide training to staff on abuse, neglect, exploitation, and misappropriation of resident property. | — |
Report Facts
Additional Lithium doses received: 10
Licensed nurses: 28
Nursing assistants: 48
Staff members: 131
Residents reviewed for nutrition: 3
Residents reviewed for drug regimen: 14
Inspection Report
Complaint Investigation
Deficiencies: 4
Apr 1, 2021
Visit Reason
A Recertification Survey and complaint investigation were conducted at Grand Islander Center from 03/29/2021 through 04/01/2021 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
The facility was found not in compliance with federal and state requirements, including failure to report an alleged injury of unknown source within 24 hours, failure to meet professional standards of quality for physician orders and care plans, failure to provide respiratory care consistent with professional standards, and failure to establish and maintain an infection prevention and control program.
Complaint Details
The complaint investigation was related to allegations of abuse, neglect, exploitation, or mistreatment, specifically failure to report an injury of unknown source involving Resident ID #60 within 24 hours as required by state law.
Severity Breakdown
SS=D: 2
SS=E: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to report an alleged injury of unknown source within 24 hours to the State Survey Agency for Resident ID #60. | SS=D |
| Failure to ensure services provided met professional standards of quality for 1 of 5 sample residents (Resident ID #37). | SS=D |
| Failure to provide respiratory care consistent with professional standards for 1 of 3 residents reviewed for oxygen therapy (Resident ID #17). | SS=E |
| Failure to establish and maintain an infection prevention and control program including proper PPE use and disinfection procedures. | SS=E |
Report Facts
ACTS reference numbers: 6
Sample residents reviewed for abuse reporting: 4
Sample residents reviewed for professional standards: 5
Residents reviewed for oxygen therapy: 3
Medication bottles observed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Center Executive Director (CED) | CED verifies state reporting and is responsible for oversight of audits and corrective actions | |
| Certified Medication Technician (Staff B) | Interviewed regarding resident positioning and care | |
| Registered Nurse (Staff C) | Interviewed regarding resident care and positioning | |
| Licensed Practical Nurse (Staff A) | Completed 'Change in skin color or condition' documentation | |
| Nurse Practitioner (Staff D) | Interviewed regarding resident bowel movement status | |
| Staff Nurse E | Observed wearing surgical mask and PPE, acknowledged PPE breach | |
| Staff Nurse F | Observed handling medication bottles and PPE breaches | |
| Director of Nursing (DON) | Acknowledged injury not reported within 24 hours and PPE breaches |
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